Pain or Depression?
Pain or Depression? | Dr. Harold G. Koenig, Center for Spirituality Theology and Health, Duke University Medical Center, Dr. Michelle Cochran, NeuroScience & TMS Treatment Center, Major Depressive Disorder, Dr. Tom Starling, Mental Health Association of Middle Tennessee, Dr. Marc Huntoon, Vanderbilt University.

Tracy Jackson, MD, of the Vanderbilt Division of Pain Medicine, performs a fluoroscopically guided block for a patient at the Vanderbilt Interventional Pain Clinic in Nashville.
Experts weigh in on chicken-or-egg controversy

Medical experts have attributed the startling trend of increased diagnoses regarding chronic pain and depression to an aging baby boomer generation enduring arguably the greatest economic fallout of our time.

And even though research shows that it’s unknown whether there’s a cause-and-effect relationship between chronic pain and depression, medical experts are scrambling to solve the riddle.

“Depression and pain often feed on each other,” said Harold G. Koenig, MD, a professor of psychiatry and behavioral sciences, associate professor of medicine, and director of the Center for Spirituality, Theology and Health at Duke University Medical Center. “Most of the time, in my experience, it’s the pain that results in depression. Chronic pain creates enormous disruptions in life. It affects sleep, physical functioning, relationships, work, play, almost every aspect. Few people can endure chronic pain without experiencing depression as a result of that pain and the life changes it causes.”

Michelle Cochran, MD, medical director of the NeuroScience & TMS Treatment Center in Nashville, Tenn., pointed out that depression is a title frequently used to refer to sadness, fatigue, loss of interest and functioning among individuals.

“However, when psychiatrists refer to Major Depressive Disorder (MDD), we’re specifically referring to an illness that’s a brain disease,” she explained. “Generally, MDD has to include an episode of at least two weeks duration and is characterized by a significant depressed mood, or a significant reduction of interests or pleasure. During this two-week period, the individual may have weight changes (gain or loss); sleep changes; activity changes that are observable by others; fatigue or loss of energy, worthlessness or excessive guilt nearly every day; diminished ability to think or concentrate or indecisiveness; and the patient may have thoughts of death or dying, or suicidal ideation.”

Cochran pointed out the symptoms must cause distress or impairment in social, occupational, or another area of functioning.  

“Physicians rule out other causes of the symptoms, like direct or indirect effects of substances, medications, other medical conditions, and bereavement,” she said. “Unfortunately, despite knowing a lot about how the brain looks and acts in a depressive state and knowing many of the treatments of the disease, the causes of depression are not well understood,” she said. “We know that significant physical, psychological, and social stressors and genetics play a large role in getting depression.”

Among the most accepted theories is that chronic pain causes the body to produce substances – adrenaline and corticosteroids – that can result in reduced functioning in areas of the pain, therefore causing or otherwise triggering a depression.  

Tom Starling, EdD, president and CEO of the Mental Health Association of Middle Tennessee, said most people who contact their office with major depression have chronic pain. 

“Some have been in motor vehicle accidents, had back surgery, and/or have chronic pain resulting from illnesses such as fibromyalgia and lupus,” explained Starling, whose wife suffers from fibromyalgia. “Studies indicate that people with chronic pain, such as fibromyalgia, may have more active pain receptors or pain pathways, so they actually feel more pain than others.”

Marc Huntoon, MD, professor of anesthesiology and chief of the division of pain medicine for Vanderbilt University, said determining the primary origin – depression or pain – is often tricky.

“Because we live in a dysfunctional world, some people may have psychological problems that stem from loss or despair related to events such as family separations, divorce and death,” he said. “In some cases, they become depressed. Others have primary depression that can be traced to a biological imbalance.”

A patient's ability to cope with the pain in the face of depression is going to be lessened, noted Huntoon.

“Their coping mechanisms will break down more readily in that situation,” he said. “Thus when depression is the first problem, we need the help of both psychologists and psychiatrists and sometimes drug therapies and counseling. Once the depression gets better, we can treat the pain more effectively.”

Conversely, sometimes the pain comes first, Huntoon said.

“Most of the time, we’re able to relieve pain in the early acute phase, but after events such as surgery, trauma or disease processes, the pain can go on long enough that it becomes chronic,” he said. “We now know that when chronic pain goes on for several months unabated, it can actually change our brain in a permanent way. When those permanent neurological changes occur, our nervous system responds to pain in a changed way. In some cases, if the associated areas in the brain that govern our emotions and mood become involved, the patient's sadness, anxiety, and isolation can also become amplified, further increasing the overall experience of pain.”

Koenig is highly skeptical about the emphasis today placed on the biological changes resulting from pain that cause brain changes resulting in depression. 

“There’s a huge push in the medical sciences to make everything biological, and to minimize the situational causes that drive depression,” he explained. “This I believe is incorrect, especially with regard to chronic pain and the disability it causes.”

Coping with chronic pain is an enormous task, emphasized Koenig, who shares chronic pain syndrome with his wife.

“Those, in my experience, who (cope) the best are people with a strong religious faith,” he said. “Religion has the potential to give the pain ‘meaning,’ which can help to transform it from a burden to a ministry. This helps not only with the pain, but also helps to neutralize the depression that results from the pain.”

Koenig is currently conducting a randomized clinical trial to see the impact patient’s spiritual resources have on their coping with chronic illness and depression.

“This study may for the first time provide direct evidence that depression associated with painful, disabling medical illness is helped by utilizing religious resources,” he said.

For more information on Koenig’s randomized clinical trial, and to determine if you have patients who might qualify for the study, call (981) 681-6633.